ORIGINAL ARTICLE 15 Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality Nekrotizan Fasiitli Olgularda Laboratuvar Risk Belirteỗleri ve Mortalite ile İlişkisi Elif COLAK, Nuraydin OZLEM, Gultekin Ozan KUCUK, Recep AKTIMUR, Sadik KESMER Department of General Surgery, Samsun Training and Research Hospital, Samsun SUMMARY ÖZET Objectives Necrotizing fasciitis (NF) is rare but life threatening soft tissue infection characterized by a necrotizing process of the subcutaneous tissues and fascial planes The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis A certain LRINEC score might also be associated with mortality The aims of this study are to determine risk factors affecting the prognosis and to evaluate the prognostic value of the LRINEC score in NF Amaỗ Nekrotizan fasiit (NF) cilt altı dokular ve fasyal planlarda nekrozla karakterize nadir görülen ama hayatı tehdit eden bir yumuşak doku enfeksiyonudur Nekrotizan fasiit iỗin laboratuvar risk indikatửr (LRINEC) skor, NF tehisinde kullanlan yararl bir tanısal yöntemdir Belirli bir LRINEC skor mortalite ile de ilikili olabilir Bu ỗalmann amac NF iỗin LRINEC skorun prognostik değerini ortaya koymak ve prognozu etkileyen risk faktörlerini belirlemektir Methods Twenty-five patients with necrotizing fasciitis treated in Samsun Education and Research Hospital between January 2008 and April 2013 were enrolled in the study Surviving and non-surviving patient groups were compared regarding demographic data, co-morbidity, predisposing factors, causative agents, number of debridements and LRINEC score Gereỗ ve Yửntem Ocak 2008-Nisan 2013 tarihleri arasında Samsun Eğitim ve Araştırma Hastanesi’nde tedavi edilen nekrotizan fasiit tanl 25 hasta ỗalmaya dahil edildi Yaayan ve ửlen hastalar; demografik özellikler, yandaş hastalıklar, presidpozan faktörler, enfeksiyon etkeni, debridman says ve LRINEC skorlar aỗsndan karlatrld Results Mean age was 55.6±16.79 years (min: 17-max: 84), and the female/male ratio was 16/9 Mortality was observed in (24%) patients The most frequent comorbid diseases were diabetes mellitus (52) and peripheral circulatory disorders (24%), and the most frequent etiologies were cutaneous (32%) and perianal abscess (20%) Pseudomonas aeruginosa infection was higher in the non-surviving group (p=0.006) The mean number of debridements and LRINEC score were higher in the non-surviving group than in the surviving group ( p=0.003 and p=0.003, respectively) Bulgular Ortalama yaş 55.6±16.70 yıl (min: 17-maks: 84), kadın/erkek oranı 16/9 idi Altı (%24) hasta kaybedildi En sık eşlik eden hastalıklar diabetes mellitus (%52) ve periferik vasküler hastalıklar (%24) idi En sık etiyoloji ise kutanöz apseler (%32) ve perianal abse (%20) idi Pseudomanas aeruginosa enfeksiyonu ölen hastalarda daha fazlaydı (p=0.006) Debridman sayısı ortancası ve LRINEC skor ölen hastalarda yaşayan hastalardan anlamlı olarak daha yüksek idi (sırasıyla p=0.003, p=0.003) Conclusions Pseudomans aeruginosa infection and multiple debridements are related with mortality The LRINEC score might help predict mortality in NF Sonuỗ Pseudomanas aeruginosa enfeksiyonu ve ỗoklu debridmanlar mortalite ile ilikilidir LRINEC skror NF iỗin mortaliteyi tahmin etmede kullanılabilir Key words: Fasciitis; mortality; necrotizing; prognosis Anahtar sözcükler: Fasiit; mortalite; nekrotizan; prognoz Submitted: 21.09.2013 Accepted: 17.12.2013 Published online: 15.01.2014 Correspondence: Dr Elif Colak Fevziỗakmak Mah., Odunpazar Cad., Mıra Evleri Sitesi, A Blok, D: 21, İlkadım, Samsun, Turkey e-mail: elifmangancolak@hotmail.com © 2014 Emergency Medicine Association of Turkey Production and Hosting by Elsevier B.V Originally published in [2014] by Kare Publishing This is an open access article under CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Turk J Emerg Med 2014;14(1):15-19 doi: 10.5505/1304.7361.2014.55476 16 Turk J Emerg Med 2014;14(1):15-19 Introduction Necrotizing fasciitis (NF), which is characterized by progressive necrosis of the fascia, subcutaneous tissue and skin, is a life-threatening soft tissue infection The disease was defined with its contemporary meaning in 1950 by Wilson, who observed that skin necrosis is a rare occurrence, but fascial necrosis is much more common.[1] Urogenital-anorectal infection and trauma plays an important role etiologically [2-4] However, NF may be caused by minor injuries such as tissue abrasions and lacerations, insect bites, and intramuscular injection; it also should be considered that there may not always be a detectable cause.[5-8] Despite immediate surgical intervention and antibiotic therapy, the mortality rate is about 20-30%.[3,4,9] Diagnosis is made by physical examination, but may be difficult since it is frequently confused with the other skin and soft tissue infections For this reason, the scoring system called Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was developed in 2004 by Wong and colleagues, and was shown to be helpful for distinguishing NF from other soft tissue infections.[10] It was reported in further studies that this scoring system can be used for early diagnosis of NF.[11-15] To calculate the LRINEC score, C-reactive protein, hemoglobin, blood leukocyte count, serum glucose, serum creatinine, and serum sodium values of patients were measured at admission and scored as shown in Table Then a certain score value is obtained for each patient Values of six or higher indicate the most likely diagnosis of NF.[10-15] The aim of this study is the clinical evaluation of patients diagnosed with NF, for whom early diagnosis and intervention are vital, and to investigate the relationship between LRINEC score and mortality rate Materials and Methods The study was approved by the ethics committee of our hospital The files of 31 patients, who were diagnosed with necrotizing fasciitis (M72.5) and were operated for Fournier gangrene with debridement (621470) code from January 2008 to April 2013, were examined retrospectively on automation system Four patients who were initially debrided in another hospital and then sent to our hospital for follow-up or intensive care support and two patients whose data were inaccessible were excluded from the study It was found that patients with skin redness, swelling, tenderness, skin necrosis, and subcutaneous crepitus had been diagnosed with NF All the patients received antibiotic therapy just after the diagnosis and underwent debridement within the first 24 hours Antibiotic treatment, which caused patients to be responsive to the factors reproduced in the deep tissue culture taken during debridement, was continued Repeated debridement was implemented for the necessary patients Table LRINEC (Laboratory risk indicator for necrotising fasciitis) score Parameters Score C-reactive protein (mg/dl) 150 Leukocyte count (mm3) 25 Hemoglobin (gr/dl) >13.5 11-13.5 135